Photo Rounds

Rash with weakness

A 61-year-old woman presented to her family physician (FP) with a new rash and some weakness. She indicated that 2 months earlier, it had become hard to climb the stairs in her home. She said she’d noticed some redness on her face, trunk, and back of her hands. She had never had a rash like this before. Upon further questioning, she admitted that it also had become more difficult to comb her hair and get out of a low chair. On physical exam, her vital signs were normal; erythema and scale were noted in multiple locations. A neurologic exam demonstrated proximal muscle weakness.

What’s your diagnosis?


Shawl sign (erythema and scale over the shawl distribution) and Gottron papules

The FP diagnosed dermatomyositis based on the patient’s proximal muscle weakness along with the typical shawl sign (erythema and scale over the shawl distribution) seen in the top image and the Gottron papules (erythematous and scaling papules over the dorsum of the fingers) and holster sign (erythema and scale over the lateral hip region) seen in the bottom image.

The FP started the patient on prednisone 60 mg/d and topical steroids for the affected areas. Laboratory exams showed an elevated creatinine kinase and mildly elevated antinuclear antibodies (typical for dermatomyositis). The FP also started the patient on oral prednisone 40 mg/d while putting in referrals for Dermatology and Rheumatology.

Two weeks later, the patient felt stronger and the rash had faded. Dermatology saw her first and started her on a steroid-sparing agent, methotrexate, with plans to taper her prednisone to lower doses over time. As underlying malignancy may precipitate dermatomyositis, the patient was screened for internal cancers—especially ovarian cancer. Fortunately, the mammogram, Pap smear, colonoscopy, and thoracic, abdominal, and pelvic computed tomography scans all were normal.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Buckley J, Burks M, Allred A, Usatine R. Dermatomyositis. In: Usatine R, Smith M, Mayeaux EJ, et al. eds. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1194-1203.

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